The Great and Good are busy trying to justify instructing the discharge of elderly patients, of uncertain Covid status, from hospitals to care homes. The result, back in March 2020, was to seed multiple care homes with Covid. The virus was then spread by staff who worked shifts for multiple sites. Care home residents account for around 45,000, or 20%, of all U.K. deaths attributed to Covid, rising to between a third and a half of those in the first wave.
Jenny Harries, then one of Chris Whitty’s Deputy CMOs and now Chief Executive of the UKHSA, e-mailed in March 2020, “The reality will be we need to discharge COVID-19 positive patients into residential care settings.” She perfectly understood the implications, last week telling the Covid Inquiry that it “sounded awful” and adding that she had been taking “a very, very high-level view”.
Matt Hancock further informed the Inquiry “The only choice is between bad options… I have gone over and over in my head the decisions that we took… Every decision was a choice between difficult options, and nobody has yet brought to me a solution to this problem that even with hindsight (my italics) would have resulted in more lives saved. If there is one, I want to know about it because it’s crucial that we learn these lessons for the future.”
What is remarkable about all this is that there was an obvious way to mitigate the problem. It’s what Sunetra Gupta, in Saturday’s Telegraph called “fever hospitals”, and what I’d call ‘cohorting’. Put simply, you take over a few care homes and you send all the possibly infected discharges there, instead of scattering them hither and thither. It’s not perfect – some uninfected discharges find themselves together with a high concentration of the infected, increasing their risk. But it’s a damned site less bad than seeding scores of sites. What’s more, you can ensure that these few sites are served by dedicated staff who aren’t also working elsewhere.
It’s basic infection control, and it’s hard to think that no one proposed it…
That said, it is just about possible, because the Department of Health has form:
From 1997 to 2011, I ran the Antibiotic Resistance Laboratory for the then Health Protection Agency (HPA), which is the UKHSA under its previous moniker but one. Any hospital that encountered unusually resistant bacteria could send them to my team for confirmation of their own results, advice on what antibiotic to use and investigation of the bug’s resistance mechanisms. We watched to see if similar resistance types were cropping-up at multiple hospitals, indicating an emerging national public health issue. Colleagues in the adjacent Hospital Infection Laboratory performed DNA fingerprinting, identifying whether new resistance types were spreading across different hospitals.
In Spring 2011, I was surprised to receive Acinetobacter and Klebsiella (genera of bacteria) from a dozen intensive care units in the same week with similar resistance patterns – but very unusual ones for the U.K. DNA fingerprinting confirmed clusters of isolates belonging to the same strains from the different ICUs. It was bizarre for something like that to arise out of the blue; multi-site problems usually build slowly and progressively.
Usefully, a couple of submission forms noted “Patient transfer from Libya”. Most other patients had Arabic names too, so we phoned around the hospitals and discovered that these too were “Patient transfer from Libya,” or were in a nearby bed to “Patient transfer from Libya.”
We gathered that the Department of Health, in its compassionate wisdom, had imported war casualties from Libya and distributed them across NHS sites, “so as not to overload a single ICU”. Other European countries had taken Libyan war casualties too, and reported similar clusters of resistant bacteria, as here, here and here.
I did my best to create a stink, raising the topic at the Government’s Antimicrobial Resistance, Prescribing and Healthcare Infections Advisory Committee. I could never find out exactly who was responsible for distributing the patients, nor what hospitals (in North Africa or Malta?) they’d passed through before reaching the U.K. Nevertheless, I felt confident that I’d created enough noise, and that the message had filtered back.
I was wrong. Later in 2011, I moved from the HPA to the University of East Anglia but, until 2018, retained a day and a half each week subcontracted to my old lab at the HPA, now PHE. I was no longer Lab Director but still chaired the Clinical Meeting, reviewing the week’s submissions. And, one week late in 2015, we had unusually-resistant Klebsiella, Acinetobacter and Pseudomonas from multiple burns units.
Once again, bacteria of the same species were similar to one another but very different from our domestic problem strains. Several Pseudomonas had a very exotic antibiotic-destroying enzyme called VEB-1 and shared a DNA fingerprint. And, this time, the local microbiologists were phoning to complain, telling us that their burns units had been instructed, with minimal notice, to accept compassionate transfers from a fire in Bucharest, coming to the U.K. for skin-grafting.
These patients had already spent many days in a Romanian burns’ unit, where their wounds had acquired an unpleasant microflora. Which was then introduced, not to one U.K. burns unit, but to several. Burns units are notorious for the spread of infection and great care is taken to prevent this. Yet, in contravention of all good practice, there was no pre-transfer screening, and no microbiology notes for the transferred patients. Worse, some patients were too unwell for grafting, meaning that their transfers were pointless, only adding to their suffering.
In each of these cases it is to the credit of the individual NHS physicians, nurses and infection control teams that they prevented, or limited, the spread of the bacteria imported to their units. There were some cross infections, but no major local or national outbreak. Malta was less fortunate: Klebsiella with OXA-48 – an enzyme that destroys the most powerful penicillin-related antibiotics (‘carbapenems’) – was imported with Libyan war casualties and thereafter swiftly became endemic across the island nation.
Each time, just as with the discharge of Covid cases, the same risks were negligently run. Possibly-infected patients were distributed to multiple sites, creating a much greater risk than if the transfers were concentrated to a few well-prepared sites. For the Libyan and Romanian stories you can support the humane intent whilst deploring the haphazard execution. In the case of Covid it is likely that the virus likely would have found the care home patients eventually anyway, but cohorting would have minimised the early deaths.
First do no harm. Will the Department of Health ever learn about ‘cohorting’? And tell Matt Hancock?
Dr. David Livermore is a retired Professor of Medical Microbiology at the University of East Anglia.